More doctors are turning to cosmetic procedures to supplement their incomes. But should you trust your OB/GYN to do your Botox?
Except for her purple scrubs and white lab coat, Dr. Connie Casad looks much like one of her patients—tousled blond hair, attractive, fit, and over 40. Her skin is smooth and unlined, even without much makeup, thanks to occasional Botox injections. Look closely and you can see the faint tattoo of permanent eyeliner around her blue eyes.
Casad began her practice as an OB/GYN in 1986. But as her life evolved, her practice did, too. After having three children of her own, she got tired of taking calls on nights and weekends, trying to keep up with kids’ activities and patients’ labor pains.
In 1997, Casad started Park Cities Aesthetics. Now she no longer delivers babies, splitting her practice between her gynecology patients—treating the symptoms of menopause and doing reconstructive pelvic surgery—and doing something she knows many doctors find frivolous: getting rid of wrinkles, doing laser hair removal, and treating spider veins.
“As I’ve aged, so has my patient population,” says Casad, now 46. “We’re all trying to age gracefully.”
Dr. Kathryn Wood of Frisco was also an OB/GYN before she quit obstetrics to spend more time with her kids. In 1999 she started a solo gynecology practice, and a year later, she added aesthetic procedures, including laser hair removal and microdermabrasion. “I had quite a few patients with unwanted hair growth, and I was referring them to other places to get that done,” Wood says. “I think a lot of women prefer to be in a medical setting for aesthetic procedures.”
Instead of switching specialities completely, Wood says many doctors are simply adding aesthetics to their practices. “A lot of doctors are dealing with managed care,” she says. “Our reimbursement is getting poorer and poorer, and we’re dealing with added costs and overhead. Plus, patients like going to someone they trust.”
Unlike Connie Casad and Kathryn Wood, Dr. Michael Roberts [not his real name] wasn’t looking for more time in his life—he wanted fewer traumas. With a background in emergency medicine, Roberts, now in his 50s, was looking for a change when he became interested in the new generation of lasers being used for facial rejuvenation.
In 1995, he opened his own aesthetic clinic. “It had nothing to do with money or time,” Roberts says. “Yes, it does give you more of those. But it was something I could do every day and be happy.” Now his patients aren’t sick, just eager. “They all want to look younger,” Roberts says, “and they don’t want to go under the knife.”
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But there’s controversy. Roberts asked not to be named because he didn’t want to be lumped together with doctors who have added aesthetics “on the side.” Roberts no longer practices his specialty and says there’s no way he could keep up with the latest techniques and research in both fields.
What does your OB/GYN know about getting rid of wrinkles? Can an emergency medicine doctor get rid of those spider veins creeping across your thighs? And why is your internist giving Botox parties at his office over lunch?
Casad, Wood, and Roberts are part of the hottest “megatrend” in medicine, which takes cosmetic procedures outside the traditional realm of dermatologists and plastic surgeons and puts them into the offices of doctors who five years ago might have sneered at catering to the vanity of their patients.
Several events have collided: rapidly evolving medical technology (particularly lasers), the aging (and narcissism) of baby boomers, and the squeezing of doctors’ incomes by insurance companies. Though the initial capital investment may be more than $100,000, cosmetic treatments are strictly pay as you go, freeing doctors from the tyranny of managed care. And it gives patients who might be embarrassed to visit a plastic surgeon the option of asking their own doctors, “Doc, don’t you think it’s time I do something about these frown lines?”
It’s a growth industry. Early this year, the American Society for Aesthetic Plastic Surgery released a survey of American physicians performing cosmetic surgery. In 2001, the physicians performed nearly 8.5 million cosmetic and nonsurgical procedures, almost 50 percent higher than the previous year’s total of 5.7 million. From 1997 to 2001, the number of cosmetic procedures jumped more than 300 percent.
Almost all types of cosmetic medicine showed hefty gains, but the biggest increases were among nonsurgical procedures. The most popular: botulinum toxin injections, which rose 2,356 percent over five years to more than 1.6 million procedures in 2001. The next four in popularity were chemical peel (1.3 million), collagen injection (1 million), microdermabrasion (915,312), and laser hair removal (854,582).
“The available population to have these treatments is 50 to 75 million people,” says Kevin O’Brien, vice president of sales for Eclipse Medical, a regional distributor for Intense Pulsed Light lasers. “The market will be growing annually until 2012, and then it will level off. It’s in its infancy. The growth curve right now is exponential.”
Casad became interested in lasers about the same time her kids hit their teenage years in the mid-’90s. She was “job sharing” with another doctor, but that still meant working 50 to 70 hours some weeks. “I loved delivering babies,” she says, “but it was not conducive to maintaining balance in my life.” But ending her obstetrics work could have meant losing half of her income. With insurance reimbursements down and overhead up, it seemed she had no choice but to continue working long hours.
At the same time, her patients were asking about treating their spider veins caused by pregnancy. “For most of my patients, I was their only physician,” Casad says, describing herself as a “womb to tomb” doctor. “Up until age 60, they may not have an internist.”
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She began investigating the “photo-derm” laser, which could treat spider veins, and realized it could answer her concerns about maintaining her practice while learning something new. Casad went to workshops and trained. “A lot of people were doing it,” Casad says, “but many were self-taught. No one was specializing in it.”
In deference to her partners, Casad bought a laser and opened Park Cities Aesthetics in a separate office away from her OB/GYN practice. “They weren’t interested in it at all,” she says. “But I was going to do it.”
Opening the office required a significant capital expense, more than $150,000 just for the machine at the time. Then Casad realized that she couldn’t simply open the office and expect patients to come. She had to—gulp—go looking for patients, something traditional doctors frown on.
“I tried to market it through my patients,” Casad says, “but I realized I would have to advertise.” Her first ads didn’t even include her name. “It was almost distasteful,” she says, “but I had to get over that aversion to marketing.”
Casad at first devoted two days a week to her aesthetic practice. “We started on a low budget and did it for a lower price to keep the machine busy,” Casad says. But her cosmetic practice slowly grew. Patients began asking about it. Three years ago, she stopped doing obstetrics altogether. With her partners’ blessing, she moved her cosmetic practice to her office at Medical City. She now offers a full range of cosmetic treatments. Casad speaks at seminars attended by physicians hit by managed care, who see their incomes eroding. “We spend a lot of time learning to do what we do,” Casad says. “It’s exceedingly frustrating to have that controlled by others.”
While other doctors now ask her about her hybrid practice, Casad admits that it goes outside the comfort zone for many. “We were trained in fairly hallowed halls to focus on medicine and health,” she says. “Even in medical school 20 years ago, no one discussed medicine as a business. We were altruistic beings.”
Kevin O’Brien of Eclipse points to a free monthly magazine called Nu Image that advertises cosmetic procedures in Dallas. He estimates that about half of the doctors who advertise are from specialties other than dermatology and plastic surgery, attracted by the burgeoning market. “It’s a consumer-driven business,” O’Brien says.
It’s a trend that promises to transform medical care, but critics point out that aesthetic treatments are mostly unregulated. Unlike breast augmentation and face lifts, which are performed by surgeons with years of specialty education, doctors with little training can perform nonsurgical cosmetic procedures.
One factor driving this trend may be a shortage of dermatologists as the technology explodes. There are about 8,000 dermatologists nationwide, less than 2 percent of all physicians. Scheduling an appointment to get in to see one can take a couple of months. Someone who wants Botox for a party on Saturday night may not be willing to wait.
Though all physicians receive some instruction regarding skin in medical school, dermatologists warn that non-derms may not understand its various reactions. The encroachment of aesthetic medicine on dermatologists’ turf bothers some skin doctors, while others are content to concentrate on more severe skin problems, offering cosmetic treatments but not aggressively marketing them.
For years, Dr. Jerald L. Sklar resisted doing cosmetic procedures such as Botox. His general dermatology practice is very busy—new patients might wait up to two months for an appointment. But he’s a Botox convert now. “It’s such a simple procedure,” Sklar says.
His practice is now 80 percent dermatology and 20 percent cosmetics, and he estimates that’s true of about two-thirds of the dermatologists in Dallas. “It’s a way of making money in medicine that’s not insurance dependent,” Sklar says. “It’s supply and demand.”
An in-house registered nurse with years of dermatology experience does Sklar’s laser hair removal, light chemical peels, and microdermabrasion. “In this setup, you’re not going to find a doctor to do your treatments,” Sklar says. “Plastic surgeons and dermatologists aren’t going to do these treatments. It’s not cost-effective.” However, one afternoon a month, Sklar does laser treatments on port wine stains and broken capillaries on the face.
When Roberts first became interested in aesthetic medicine, he realized he knew little about the skin. He spent months researching the literature and training with the laser. “Laser technology is growing so rapidly,” Roberts says. “This is a whole new area of medicine. We have learned more about skin in the last five years than in the previous 20. There are now 200 different kinds of microdermabrasion machines. It’s impossible to keep up. I focus day and night on this.”
Roberts warns that consumers should be wary, particularly of clinics where a doctor isn’t on-site. He recommends asking how much training the physician or aesthetician has had in various procedures. Lasers—used for everything from laser hair removal to elimination of sun damage—can cause burns and scarring. The Texas State Board of Medical Examiners has proposed new legislation limiting laser hair removal to facilities where the doctor is on-site and requiring a doctor to see each new patient before treatment begins. The proposal is controversial: currently, some clinics have no doctors in-house. The physicians serve as “medical advisers” but may not be available to treat complications.
Wood says either she or a nurse practitioner is always at her clinic. “There are just times when you need to see a doctor,” she says. “I think it’s important, but I know that’s not how things are always being done.”
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Though many doctors allow their nurses to do Botox injections, neither Sklar nor Roberts does. “Once you start getting into too much of that,” Sklar says, “you lose credibility. There are no standards anybody has to go by, no certification for Botox or lasers. Many of these are very simple procedures, but there’s still some variability there.” Even if a non-physician is going to perform the procedure, a doctor should evaluate the patient and be available for follow-ups.
“A lot of times non-plastics and non-derms won’t know how to handle complications on the skin,” Sklar says. “With the lasers and the peels, we see things like atypical herpes infections, yeast and bacterial infections, and atypical scarring reactions—even allergic reactions to some of the products used. There are so many variables. Treating these things is what we do every day.”
The bottom line: consumer beware. The number of people seeking aesthetic treatments is growing so rapidly that the current population of “derms and plastics” can’t meet the needs, says O’Brien. “We’re only scratching the surface of consumer demand.”
Glenna Whitley is a D Magazine contributing editor.
